Paying Attention to Pain

A young woman decides to terminate a pregnancy a month before she was scheduled for heart surgery. She intended to share the news of her abortion only with those closest to her, like her boyfriend and her parents. But her mother insists that she tell her cardiologist, in case the procedure threatens her vascular condition. The patient, feeling ashamed, musters the courage to tell the doctor, a small, curt woman who had never been warm to her.

"And what do you want to know from me?" the cardiologist responded, her voice cold and blunt.

The patient's mind went blank. She started crying, then asked: Did the abortion doctor need to know anything about her heart procedure?

"No," the doctor said. She paused. "Is that it?"

That sharp question, "Is that it?" well represents what motivated author Leslie Jamison to write The Empathy Exams, an essay compilation that won the Graywolf Press Nonfiction Prize. The doctor's lack of empathy trivialized the patient's feelings, causing her to question whether she was "making a big deal out of nothing." Jamison was the young patient in this story. Through eleven essays, Jamison serves as her own protagonist, sometimes as the giver and sometimes as the recipient of empathy. On other occasions, like that in the example above, she is denied empathy. Jamison explores empathy as it relates to guilt, shame, trauma, power, agency, blame, and forgiveness. Her essays appeared in nine different literary journals before Jamison published them together in this book. The meaning of empathy floats throughout the collection, presenting itself as a fluid feeling, without discrete edges, rather than as a dictionary-defined word. Jamison steers through the topics with masterful prose, no doubt honed by her studies at Harvard, Iowa, and now Yale, as a doctoral student in English literature. Jamison is also an accomplished fiction writer, and her first novel, The Gin Closet, won awards from the Los Angeles Times and the San Francisco Chronicle. In taking on a topic as complex as empathy, perhaps Jamison intended for the reader to define the word, using her book as inspiration.

Though she doesn't quite frame it this way, Jamison's essays appear to converge on this point: empathy is the salve for human loneliness. "We care in order to be cared for. We care because we are porous," Jamison writes. She aims to prove this point empirically. She tackles subjects that include her own medical history, the unexplained disorders of others, prisons, marathon races, murder cases, and feminine pain. She moves the narrative from Austin, Texas, to Mexico, from Nicaragua to West Virginia. The philosophical, geographical, and topical scope of The Empathy Exams, with Jamison playing both narrator and character, leads the reader to consider how voicing empathy heals the giver as much as the recipient.

The book begins with the title essay. Here, we see Jamison trying to make ends meet as a writer by playing a medical actor for $13.50 an hour. Her job is to dramatize ailments as spelled out in fictional case studies. Medical students enter examination rooms and interview actors like Jamison, trying to diagnose their pretend disease. For example, Jamison's specialty is playing a twenty-three-year-old woman who has a psychiatric disorder borne of grieving. She reveals bits and pieces of her symptoms to the medical students based on their questions and emotional connectivity with her. After the skits, the actors evaluate the medical students' performances. The more information a medical student convinces the actor to divulge, the better the actors will grade the aspiring doctor.

Checklist item 31 of the evaluation reads: "Voiced empathy for my situation/problem." The hospital personnel running the program underscore "voiced" as the critical component of this metric. Jamison does not delve into the fact that this is item thirty-one, after thirty previous questions about the diagnosis itself. Empathy in this setting is relegated to part two of the evaluation, with diagnostic science taking precedence over emotional connectivity. Jamison's interaction with her cardiologist reflects that ordering. The essay toggles between Jamison's role as medical actor and her life predicament as patient; in the one case, empathy is dramatized, and in the other situation, it really matters to her.

Part memoir and part journalism, the mixed genre of The Empathy Exams also allows Jamison to investigate a wide range of emotions, both as observer and as participant. She divulges her guilt and shame over her unplanned pregnancy. She exposes the superficiality of comments such as "That must be really hard," or "I couldn't even imagine"—banal offerings that exacerbate the isolation of trauma instead of alleviating it. She discusses the tension over needing to handle trauma alone and simultaneously needing emotional support.

Jamison's eclectic writing style models her apparent philosophy that there are no tidy solutions to human pain. Her approach to writing is interdisciplinary, and she attempts to bridge academic disciplines with popular writing. She defies market pressures that sort books into rigid categories: academic or trade, nonfiction or memoir, anthropology or psychology. She cites an expansive range of sources, including Susan Sontag, Joan Didion, Guns N' Roses, and Maurice Merleau-Ponty. Readers from academic circles may search through her text for how empathy relates to broader frameworks like feminism, race, class, or moral philosophy. Nonacademics might find the external references distracting. But Jamison's mixed style results in a book just sophisticated enough for anyone to take away an emotional and intellectual education about a universal human feeling. The essays offer insights about empathy without insisting on answers. Jamison's approach to empathy is, well, empathetic.

Jamison discusses what I view as a loneliness-empathy construct in each of the other essays in the book. In the essay "Devil's Bait," for example, she travels to Austin, Texas, to attend a conference about Morgellons disease, a condition where matter like long fibers, fuzz, crystals, and specks mysteriously grow out of people's bodies. She exposes, in graphic detail, the symptoms of the disease and how isolated those afflicted with it feel. Morgellons patients suffer severe dermatological disfigurement, aching to scratch out the invaders lying under their skin. Yet medical studies and doctors question the disease, considering it one of delusion, made up, or a joke. There is no known cure for Morgellons. Patients end up defending a disease that is a living nightmare. Jamison wonders whether the disease is contagious after she spends several days locked in an Austin church with a group of self-diagnosed patients. She feels guilty about her relief over leaving the conference early. As an author who craves empathetic care, she recognizes the difficulties in giving empathy.

Through the essays, Jamison also probes at how isolation and empathy feel in different spaces. The intimacy of a hospital examination room, for example, can inspire empathy or emphasize isolation, depending on eye contact, tone of voice, and reaction to someone's pain. The church conference room gathered sick people who needed to feel validated. Still, after sitting through lectures about how frustrating the ailment was and how powerless its victims felt, Jamison asks, "When does empathy actually reinforce the pain it wants to console?" She explores in another essay the difference between Watts and Santa Monica when a person says they are "from" Southern California, citing the shame of privilege in saying that a person is from "here" when their sense of "here" is wildly different in Santa Monica than it is in Watts.

Prisons also affect empathic feeling, in Jamison's view. Jamison compares her freedom, without walls, restrictive routine, or shackles, to an inmate's opposite predicament. However, she pays little regard to the volitional criminal acts that land inmates in jail. In her two essays about inmates, Jamison expresses greater empathy for inmates than for victims or the correctional system. Perhaps the judgment here derives from her role as observer rather than participant. Jamison devotes no time to thinking about why our system incarcerates people. Or, again recalling the title essay of the book, she neglects discussing why empathy ranks thirty-one on the list of questions after thirty diagnostic questions. There is a flaw in Jamison's policy critiques when her empathy serves only one person, without considering how large systems process human trauma.

That said, her witness perspective has value. She identifies how both the health care and the criminal justice systems can grow emotionally mechanical in handling social problems. People working in health care or criminal justice see illness, crime, pain, and punishment so often that they can become desensitized. Observations that shock Jamison and many of her readers may feel banal or commonplace to those working inside hospitals, jails, and courtrooms. Jamison's cardiologist, for example, brushed her question off as perfunctory because, to her, it probably was. That desensitization might exist because pain loses its novelty to these insiders, or because actors within the system would burn out if they constantly invoked empathy for the causes they serve. Jamison urges the reader to consider whether we can afford for empathy to be an afterthought in medical and legal contexts. She suggests that we must summon empathetic responses in these situations.

A race with only thirty-five runners who compete at risk of grave injury, the Barkley Marathons is an event that requires an understanding of why and how people need this paradoxical sense of shared solitude. Photos: Geoffrey Baker.

This need for empathy plays itself out in another essay about extreme sports and the Barkley Marathons, a trail race that grew out of a famous attempted prison break. James Earl Ray, the man who shot Martin Luther King Jr., escaped from a penitentiary in northern Tennessee in 1977 and was caught after more than fifty hours of running and covering a distance of barely eight miles. The terrain he covered is so treacherous that since the race began, in 1986, only a dozen men have finished it. The runners begin, lost deep in the woods, and then make their way alone across one hundred miles of steep hills, brutal saw briars, and a tunnel under the old penitentiary grounds. Men (and a few women) compete in this ultra-marathon at risk of grave injury. Taking part in this race is a driving need for its participants, even if health concerns and pragmatism counsel against running it.

This extreme sport is Jamison's way of depicting what happens when someone makes a confounding choice. For her, that choice was to have an abortion, or, in other essays, to cut her skin, to drink heavily, and to live with an eating disorder. She also writes about a grandmother who contracts a sexually transmitted disease while having an affair. When an outsider observes something that seems inexplicable, incomprehensible, or morally wrong, Jamison asks us to consider how that reaction affects both the actor and the observer. In the context of an extreme sport, being alone is a deliberate choice. This essay probes whether we should feel empathy for those who have made questionable choices and whether they need us to feel empathy for their situation. Her answer to the first question is "yes," while she leaves the latter question open. Jamison writes: "Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see." A race with only thirty-five runners a year, the Barkley Marathons is an event that requires an understanding of why and how people need this paradoxical sense of shared solitude.

Making this effort to be empathetic, in Jamison's view, is a deliberate act. The empathy need not be tailored to one situation or to one script. "Empathy isn't just something that happens to us—a meteor shower of synapses firing across the brain," Jamison says. "[I]t's also a choice we make: to pay attention, to extend ourselves." She admits in two essays, "In Defense of Saccharin(e)" and "Grand Unified Theory of Female Pain," that her view on empathy may be sentimental. Parts of her book are melodramatic, a risk in the genre of self-writing. But Jamison anticipates this critique, arguing that melodrama should be understood as an acceptable, even necessary, human indulgence. There should be no shame in expressing pain or self-pity, she says, admitting, "I'm not sure how to say it right, with the kind of language that would be sentimental enough to support its point but not too sentimental to damn it." Jamison's book pays homage to the idea of sharing pain, as the essays themselves narrate the author's own experiences as observer and participant in life's traumas. "I don't believe in a finite economy of empathy," she insists, "I happen to think that paying attention yields as much as it takes. You learn to start seeing."

Jamison's clarity of vision, as an author, academic, journalist, and ordinary person, offers readers multidimensional representations of some of the most difficult experiences a human can face. The eleven essays leave the reader feeling emotionally spent but also hopeful that caring for someone else helps heal our own pain. We all make mistakes, fail at something, fall ill, or judge too harshly. Jamison insists that we are wrong to believe that we carry guilt, shame, and self-blame alone. Quoting Joan Didion, Jamison reminds us: "We tell ourselves stories in order to survive." The Empathy Exams is one author's manifesto of survival out of loneliness—her petition for empathetic connection. "I want our hearts to be open," Jamison concludes. "I mean it."

Sejal H. Patel is a former federal prosecutor and criminal defense attorney. She recently graduated from Harvard Divinity School (MTS '14), where she finished her first book and produced documentary films.